Oral Antimicrobial Pharmaceutical Compositions

ABSTRACT

The present invention relates to oral pharmaceutical compositions with controlled and/or programmed release containing at least one active ingredient having antimicrobial and/or anti-infectious activity for the treatment of infections of the large intestine, in particular the colon.

Intestinal infections are common diseases caused by the colonization ofthe intestine by foreign pathogenic agents of various origins, or causedby intestinal microorganisms that are normally present becomingvirulent.

It is known that the intestine is divided into two distinct portions:the proximal portion, called the “small intestine”, which is formed, inthe craniocaudal direction, by the duodenum, the jejunum and the ileum,and the distal portion, called the “large intestine”, which is formed bythe colon and the recto-anus (Faller A, Scevola G. Anatomia e Fisiologiadel Corpo Umano (Anatomy and Physiology of the Human Body). Vol I.Edizioni Minerva Medica, Turin, 1973, pp. 235-254).

The two portions, the small intestine and the large intestine, arecompletely separated anatomically by the ileocaecal valve which permitsthe passage of the intestinal contents from the small intestine to thelarge intestine but not vice versa Besides from theanatomical-structural point of view, the large intestine is quitedifferent from the small intestine also, and above all, from thefunctional point of view (Braga P C Enteric microflora and itsregulation. In Drugs in Gastroenterology. Raven Press, New York, 1991,pp. 501-508).

While the small intestine is assigned to the digestion of the majorityof the food, to the absorption thereof, to the production of B-complexvitamins and vitamin K, to the metabolism of biliary acids and variousother organic substances and to the rapid transfer of the alimentarybolus to the sections further downstream, the large intestine providesfor the absorption of water, for the digestion of vegetable fibres andfor the completion of some digestive processes initiated in the smallintestine. In addition, the large intestine differs from the smallintestine by the presence of an extremely rich bacterial flora, thebalance of which is of fundamental importance in regulating the ambientpH, motility, the production of gas and ammonia, the formation offaeces, and the production of metabolites essential for maintaining thegood functioning of the large intestine.

These many differences between the small intestine and the largeintestine explain the distinctive nature of some pathologies which occurat the expense of the large intestine and in particular the colon.

The colon is the portion of the large intestine that is host to themajority of the bacterial strains and that offers conditions of pH,anaerobiosis, humidity and slowness of transit that are particularlysuitable for the permanent flora potentially becoming virulent or forthe proliferation of and colonization by pathogenic bacteria. For thosereasons, the colon is the sector of the intestine most susceptible toinfection; in fact, infections located in the colon (infectious colites,bacillary dysentery, diarrhoea, pseudomembranous colitis,diverticulitis, etc.) constitute an important and autonomous chapter inthe gastroenterological monograph (Sorice F., Vullo V. Intossicazionialimentary e infezioni del tubo digerente. (Food Poisoning andInfections of the Alimentary Canal). In: Medicina Clinica (ClinicalMedicine). Edizioni Medico Scientifiche, Turin, 2002).

In addition, the increased endoluminal pressure, linked with theproduction of gas and associated with predisposing local factors, canpromote the occurrence of diverticula which are susceptible to infectionand inflammation and which are located exclusively in the colon (JacksonB T. Diverticular disease. In: Inflammatory Bowel Diseases ChurchillLivingston, N.Y., 1997, pp. 443-447).

Currently, the oral therapy of intestinal infections, and in particularcolon infections, uses substances having antibacterial activity whichmust have specific characteristics such as: broad spectrum of activityon Gram+ and Gram− bacteria, resistance to strongly acidic environments,such as the gastric environment, anti-infectious activity independent ofthe presence of the intestinal biomass, residence inside the intestinefor an appropriate period of time, good penetrability into the infectinghost cell and good tolerability (Braga P C. Interaction of antibioticson enteric microflora In: Drugs in Gastroenterology. Raven Press, NewYork, 1991, pp. 509-517).

Therapy with antibacterial agents administered in the oral preparationsemployed today has at least two limitations. In the first place, theantibacterial agents, if not suitably protected, may lose their efficacyowing to the enzymatic or degradative inactivation which occurs duringtheir passage through the stomach or through the small intestine.

In addition, the pharmaceutical forms nowadays used, although theypermit the administration of the active ingredient in discrete doses,release it too rapidly in relation to the time taken to pass through thedigestive tract, so that the active ingredient performs itsanti-infectious activity in an indiscriminate manner along the entiregastro-intestinal tract.

This leads to the disappearance of the non-pathogenic bacterial floraliving in the small intestine (duodenum, jejunum and the ileum), whichflora, since it is not normally the seat of infection, should beprotected and not subjected to the sterilizing action characteristic ofthe formulations used today.

For it is known that this bacterial flora is important in fundamentalbiological processes, such as, for example, the digestion and absorptionof alimentary nutritive components, the production and absorption ofvitamins (vitamin K and B-complex vitamins), the metabolism of biliaryacids and of steroid hormones, the activation and inactivation ofvarious substances, the protection of the organism from xenobiotics,(Braga P C. Ibidem).

In particular, the usual oral antibacterial therapies for the treatmentof pathologies located in the colon have often given a contradictoryresult, probably owing to the excessive dilution of the activeingredients in the intestinal lumen; this dilution is caused by thepremature release of the antimicrobial agent from the pharmaceuticalform containing it, which takes place as early as in the stomach and inthe immediate vicinity of the patient's pyloric valve.

In addition, although the antimicrobial agents used for the disinfectionof the digestive tract often do not have a high rate of metabolism, inorder to maintain unaltered the therapeutic possibility connected withthe administration of a traditional form containing antimicrobialagents, no phenomenon of metabolic degradation should occur, in order toavoid any weakening of the therapeutic efficacy associated with thepresence of the antimicrobial agent.

Therefore, in such cases, in order to ensure the real efficacy of theanti-infectious therapy, it is felt that there is a need for thepossibility of a controlled and site-specific form of administration.

For the release of the antimicrobial/anti-infectious active ingredientin the immediate vicinity of the region where a diverticulum or ageneric infection becomes established, leads to the formation of a muchhigher concentration gradient than in the case of a conventional form oforal administration, with the consequent greater possibility that theantimicrobial agent will succeed in penetrating to the inside of thediverticulum.

In that situation, particular importance is attached to the possibilityof the remission also of infectious pathologies which are not widespreadbut which are of considerable socio-epidemiological importance, such asbacillary dysentery and pseudomembranous colitis, and also of infectiouscomplications in surgical operations at the expense of the largeintestine and in particular the colon. Rifamicin SV, which has beenknown since the 1960s, is a semi-synthetic active ingredient which isderived from rifamicin S and which has a strong antimicrobial and/oranti-infectious activity both locally and parenterally. Its activity hasalso been evaluated in vitro at minimum concentrations (mcg/ml) on Gram+bacteria, such as Staphylococcus aureus or Enterococcus faecalis, aswell as at higher concentrations on Gram− bacteria, such as Escherichiacoli, Salmonella, Enterobacter aerogenes, Enterobacter cloacae orPseudomonas aeruginosa.

Rifamicin SV, in the form of its sodium salt, is currently marketedunder the name Rifocin® both for external topical use and for injection.In particular, the topical use, indicated for the local treatment ofinfectious processes, is limited to external use by means of a solutionof the active ingredient which is to be diluted at the time of use.

Patent application WO01/1 1077, which is incorporated herein byreference, describes the use of antimicrobial agents, including thegeneric rifamicin, for the preparation of pharmaceutical compositionsthat can be used in the treatment of pathologies caused by anomalousbacterial growth (Small Intestine Overgrowth—SIBO) at the expense of thesmall intestine. Those compositions are formulated in such a manner asto release the active ingredient rapidly in the proximal portion of theintestine, that is to say, solely in the small intestine (duodenum,jejunum and ileum).

Metronidazole is a nitroimidazole chemotherapeutic agent having powerfulantimicrobial activity and a broad spectrum of action both on Gram+bacteria and Gram− bacteria. In addition, metronidazole is known to havea proven antiprotozoan activity (Tracy J W. et al., Metronidazole, in:Goodmen & Gilman's, The Pharmacological Bases of Therapeutics, IX Ed.,1996, pp 995-998). Current therapy with metronidazole is supported withtablets (Flagyl®) that contain 250 mg of active ingredient and that areformulated for immediate release. It has now surprisingly been foundthat the efficacy of antimicrobial/anti-infectious active ingredients,such as rifamicin SV and/or metronidazole, in the treatment ofinfections of the large intestine, and in particular of the colon, canbe substantially potentiated thanks to the elimination of the undesiredeffects described above (avitaminosis, destruction of non-pathogenicbacterial flora, etc.) which are caused by the premature release of theactive ingredients in the first portions of the digestive canal, such asthe stomach, the duodenum and the jejunum, and thanks to the protectionfrom the metabolic-enzymatic inactivation of the active ingredientswhich is brought about before the ingredients can reach the site ofinfection.

In particular, the efficacy of rifamicin SV was verified by means of anevaluation of the MIC (Minimum Inhibiting Concentration) on specificpathogenic bacterial strains, such as, for example, Escherichia coli,Enterobacter faecalis, Proteus vulgaris, Pseudomonas aeruginosa,Salmonella typhi and Enterobacter cloacae as shown in the followingTable A. TABLE A Bacterial species MIC (mcg/ml) Escherichia coli (ATCC30218) 400 Enterobacter faecalis (ATCC 29212) 25 Proteus vulgaris (ATCC13315) 400 Pseudomonas aeruginosa (ATCC 27853) >400 Salmonella typhi(ATCC 13331) >400 Enterobacter cloacae (ATCC 17446431) >400Staphylococcus aureus (ATCC 25213) <0.4

The present invention therefore relates to oral pharmaceuticalcompositions containing an active ingredient havingantimicrobial/anti-infectious activity, such as rifamicin SV and/ormetronidazole, characterized in that they are formulated in such amanner as to release the active substances substantially in the portionof the large intestine where their specific sterilizing action isrequired, but leaving unaltered the non-pathogenic bacterial florapresent in the portions of the small intestine which are not affected bythe infection.

In particular, the formulations according to the present invention arecapable of releasing the active ingredient solely in the colon, thusensuring localized and restricted anti-infectious efficacy.

Consequently, the advantage of the formulations of the invention is theparticular site-specificity in the large intestine, and in particular inthe colon, which permits a greater concentration of the active substancein the infected distal intestinal region with complete preservation ofthe healthy proximal regions.

This advantage is displayed mainly during the treatment of specificpathological situations in the colon region, such as infectious colites,bacillary dysentery, diverticular disease and diverticulitis where thesite-specificity and the tolerability of the formulations play a keyrole in the resolution of the pathology.

A further advantageous application of the formulations of the inventionis their use during preparation for surgical operations on the largeintestine, in ileocolic anastomoses, and in the sterilization of theammonia-producing colonic flora in order to prevent and/or treathyperammonaemias. In these last-mentioned cases, the site-specificity oftreatment and the consequent concentration of the activity of the activeingredient may lead to a significant resolution of cases which wouldotherwise involve substantial complications.

In the formulations of the invention, the substances havingantimicrobial/anti-infectious activity are contained in an amount offrom 10 to 90% by weight; in particular rifamicin SV is contained in anamount of from 20% to 60% by weight, while metronidazole is contained inan amount of from 25% to 70% by weight. The oral formulations of theinvention are selected from tablets, capsules, granules and/ormicrogranules.

A preferred embodiment of the present invention comprises a system forcontrolled release which is characterized by the presence of a first,amphiphilic, matrix in which the active ingredient is incorporated andwhich is in turn dispersed in a second, lipophilic, matrix. The form soobtained is again in turn dispersed in a third, hydrophilic, matrixbefore producing the final oral pharmaceutical form.

The lipophilic matrix of the present invention is represented bysubstances having a melting point lower than 90° C., such as, forexample, beeswax, carnauba wax, stearic acid, stearin and the like; theamphiphilic matrix is represented by substances selected, for example,from phospholipids, ceramides, sphingomyelins, lecithins, alkyl blockcopolymers, salts of sulphated alkyl acids, polyoxyethylenated alkyl,derivatives of sorbitan and the like, while the hydrophilic matrix isrepresented by generally cross-linked or linear polymeric or copolymericsubstances, which are known as hydrogels, that is to say, substancescapable of increasing their mass and their weight, owing to the polargroups present in the main or side polymer chains, when they come intocontact with molecules of water.

In particular, the hydrophilic matrix corresponds to substancesselected, for example, from cellulose derivatives, such ashydroxyalkylcelluloses, alkylcelluloses, carboxyalkylcelluloses andtheir salts or derivatives, polyvinyl alcohols, carboxyvinylderivatives, polysaccharide derivatives of anionic or cationic nature,such as, for example, hyduronic acid, glucuronic acid, or glucosamines,pectins and/or their derivatives.

In this preferred embodiment, the matrices are dispersed in one anotherin succession together with the active ingredient, thus bringing aboutthe formation of a homogeneous structure responsible for thesite-specificity of release.

In a further embodiment of the present invention, the tablets obtainedare finally subjected to a coating process using gastroresistantsubstances, such as, for example, polymers of acrylic and methacrylicacids (Eudragit) and/or derivatives of cellulose phthalate.

Systems of controlled and/or programmed release suitable for the presentinvention are described in EP 1183014, GB 2245492 and EP572942, whichare also incorporated herein by reference.

The following Examples describe the invention in detail without limitingthe content thereof in any way.

EXAMPLE 1

200 g of rifamicin SV are mixed with 5 g of stearic acid, 7 g ofcarnauba wax, 8 g of sodium dioctyl sulphosuccinate, 100 g of lactoseand 10 g of sodium edetate and granulated with a solution containing 25g of low-viscosity polyvinylpyrrolidone in 0.2 litre of purified water.When the granulate has been dried, it is mixed with 100 g of sodiumcarboxymethylcellulose, 25 g of silica, 5 g of glycerol palmitostearateand 10 mg of talcum before being subjected to compression to the unitweight of 495 mg/tablet The cores so obtained are then film-coated witha hydroalcoholic dispersion of acrylic and methacrylic acid esters,titanium dioxide, talcum and triethyl citrate, which confers on theproduct resistance to disintegration in a strongly acidic environment,simulating the environment of the stomach and the small intestine. Thedissolution of the tablets is practically zero in pH conditions of lessthan 7 and is progressive in an enteric buffer at pH 7.2 with thefollowing percentage quotas:

-   -   less than 20% after 1 hour's residence,    -   less than 50% after 3 hours' residence,    -   more than 70% after 8 hours' residence.

EXAMPLE 2

500 g of rifamicin SV are mixed with 10 g of stearic acid, 10 g ofbeeswax, 10 g of sodium lauryl sulphate, 200 g of mannitol and 10 g ofsodium edetate and granulated with a solution containing 50 g ofhydroxypropylcellulose in 0.5 litre of water. When the granulate hasbeen dried, it is mixed with 150 g of sodiumhydroxypropylmethylcellulose, 25 g of silica, 5 g of glycerolpalmitostearate and 10 mg of talcum before being subjected tocompression to the unit weight of 490 mg/tablet. The cores so obtainedare then film-coated with an aqueous dispersion of acrylic andmethacrylic acid esters, iron oxide, talcum and triethyl citrate, withconfers on the product resistance to disintegration in an acidicenvironment, simulating the environment of the stomach and the smallintestine. The dissolution of the tablets is practically zero in pHconditions of less than 7 and is progressive in an enteric buffer at pH7.2 with the following percentage quotas:

-   less than 30% after 1 hour's residence,-   less than 60% after 3 hours' residence,-   more than 80% after 8 hours' residence.

EXAMPLE 3

2.5 kg of metronidazole are mixed with 70 g of stearic acid, 70 g ofbeeswax, 400 g of saccharose, 140 g of hydroxypropylmethylcellulose and20 g of polysorbate and wet-granulated by the addition of purified waterto a suitable consistency. The granulate is then dried and standardizedin terms of dimensions before the addition of a further 200 g ofhydroxymethylpropylcellulose, 600 g of microcrystalline cellulose, 30 gof glycerol palmitostearate and 70 g of silicon dioxide. After mixing,the powder is sent for compression to the unit weight of 450 mg/tablet

The cores so obtained are then subjected to film-coating with ahydroalcoholic dispersion of acrylic and methacrylic acid esters, ironoxide, talcum and triethyl citrate, which confers on the productresistance to disintegration in an acidic environment. The dissolutionof the tablets is practically zero in pH conditions of less than 7 andis progressive in an enteric buffer at pH 7.2 with the followingpercentage quotas:

-   less than 25% within the first hour of residence,-   more than 25% and less than 70% within the third hour of residence,-   more than 80% after 8 hours' residence.

EXAMPLE 4

500 g of metronidazole are mixed with the components of thelipophilic/amphiphilic matrix, 5 g of stearic acid and 5 g of soyalecithin, some of the hydrophilic polymer, 100 g ofhydroxypropylcellulose, and diluents, 150 g of mannitol.

The mixture is then made into a paste with a solution of low-viscosityhydroxypropylcellulose in purified water until a consistent granulate isobtained. After drying, the granulate obtained is mixed with a further100 g of hydroxypropylcellulose, to which are added flow agents andlubricants, 5 g of silica, 5 g of talcum and 5 g of magnesium stearate,then compressed to a final weight of 925 mg/tablet. The tablets arefinally coated with an alcohol-based suspension of acrylic andmethacrylic copolymers capable of imparting to the tablets efficaciousgastroresistance.

The rate of dissolution of those tablets is progressive and controlled,with approximately 20% of the active ingredient being released after thefirst hour of residence in enteric juice at pH 7.2, 50% after 2 hoursand more than 80% after 4 hours, these figures being understood asquotas that are clearly subsequent to 2 hours' exposure at pH 1 and 1hour's exposure at pH 6.4, reflecting the environment of the stomach andof the small intestine, respectively.

1-17. (canceled)
 18. Controlled and/or delayed release oralpharmaceutical compositions containing rifamicin SV in association withone or more pharmacologically acceptable excipients(s), wherein thecontrolled and/or delayed release is given by a multi-matrix structurecomprising: a) an amphiphilic matrix in which the active ingredient isincorporated; b) a lipophilic matrix which is formed by substanceshaving a melting point of less than 90° C. and in which a) is dispersed;c) a hydrophilic matrix.
 19. Pharmaceutical compositions according toclaim 18, wherein the release of the active ingredient takes place inthe large intestine.
 20. Pharmaceutical compositions according to claim18, wherein the release of the active ingredient takes place in thecolon.
 21. Pharmaceutical compositions according to claim 18, whereinthe rifamicin SV is contained in an amount of from 10 to 90% by weight.22. Pharmaceutical compositions according to claim 18, wherein therifamicin SV is contained in an amount of from 20 to 60% by weight. 23.Pharmaceutical compositions according to claim 18, wherein theamphiphilic matrix is selected from lecithin, polyoxyethylenatedsorbitan monooleate, sodium lauryl sulphate, sodium dioctylsulphosuccinate and/or ethylene and/or propylene block copolymers. 24.Pharmaceutical compositions according to claim 18, wherein thelipophilic matrix is selected from stearic acid, beeswax, carnauba wax,palmitic acid and/or palmitostearate esters.
 25. Pharmaceuticalcompositions according to claim 18, wherein the hydrophilic matrix isselected from hydroxypropylcellulose, hydroxypropylmethylcellulose,sodium carboxymethylcellulose, hydroxyethylcellulose, carboxyvinylpolymers, polyvinyl alcohol, vinyl polymers, alginic acid and its saltsand/or polysaccharide polymers.
 26. Pharmaceutical compositionsaccording to claim 18, comprising a gastro-protective coating. 27.Pharmaceutical compositions according to claim 26, wherein thegastro-protective coating is selected from acrylic and methacrylic acidesters and/or cellulose acetate phthalate.
 28. Pharmaceuticalcompositions according to claim 18, for the treatment of pathologies ofthe large intestine.
 29. Pharmaceutical compositions according to claim18, for the treatment of pathologies of the colon.
 30. Pharmaceuticalcompositions according to claim 18, for the treatment of infectiouscolites, bacillary dysentery, pseudomembranous colitis, travellers'diarrhoea, diverticular disease and/or diverticulitis. 31.Pharmaceutical compositions according to claim 18, for preparationtreatment for surgical operations on the colon and/or for supporttreatment in the therapy of ammonaemias or hyperammonaemias